Volunteer Background Check Form

*STOP*

Have you received principal approval to volunteer? Only proceed with this form if you've been approved to volunteer by a principal in the District.

>> Review our Volunteer Guidelines Here <<

Permission to Conduct a Records Check With Supporting Agencies

Student’s Name(s) or Activity *

School(s) *

VOLUNTEER INFORMATION

First Name *

Middle Initial *

Last Name *

Maiden Name

Social Security Number *

Date of Birth * +

Street Address *

Address Line 2

City *

State *

Zip Code *

County *

Phone Number *

Email Address *

By signing below, I hereby give permission for the Director of Human Resources for the Sioux City Community School District to conduct a records check with any local police department, the Iowa Department of Criminal Investigations, or other state criminal records and the Department of Human Services. I understand that a negative report could be grounds for dismissal as a volunteer with the Sioux City Community School District. I further understand that a felony conviction will generally result in the denial of an application to volunteer and that other criminal records may also be grounds for the denial or dismissal of a volunteer.

Signature *

clear

Date of Signature * +

NON-DISCRIMINATION STATEMENT:

The Sioux City Community School District offers career and technical programs in the following areas: Business & Marketing, Family & Consumer Science, Health Science, and Industrial Arts, Technology, & PLTW.

The Sioux City Community School District is an equal opportunity/affirmative action employer and does not discriminate on the basis of race, creed, color, sex, sexual orientation, gender identity, genetic information (for employment), national origin, religion, age (for employment), disability, socioeconomic status (for programs), marital status (for programs), or veteran status (for employment) in its educational programs and its employment practices. The District is required by Title IX and 34 CFR Part 106 not to discriminate on the basis of sex in its programs, activities, or employment.

Inquiries or grievances under Section 504 and Title II of the Americans with Disabilities Act may be directed to Dr. Dora Jung, Director of Student Services/Title IX Coordinator at 627 4th Street, Sioux City, IA 51101, (712) 279-6075, jungd@live.siouxcityschools.com. Inquiries about the application of Title IX and its regulations to the District may be referred to the Title IX Coordinator, the Assistant Secretary of the U.S. Department of Education, or both. Please see District Board policies 103 and 504.4 for additional information on available grievance procedures.